Prepared by: Rosdina Zamrud Ahmad Akbar
Supervised by: Dr Lim Wan Chieh, Dr Cheah Wee Kooi
Title: Rapid Cognitive Decline in Parkinson’s Disease
Mr. YAF is a 70-year-old man who previously worked as a cook. He has diabetes mellitus, hypertension, dyslipidemia, and stroke in 2014, with no neurological deficits or cognitive decline. In 2022, he was diagnosed with Parkinson's disease, initially presented with a slow gait, difficulty turning, tremors, and constipation for the past two years. He appropriately sought treatment in May 2024 after being lost to follow-up since 2022. He was prescribed Levodopa/Benserazide at a dosage of 62.5 mg three times a day (8 AM, 12 PM, and 4 PM).
During clinic session, his granddaughter's primary concerns were his visual hallucination and insomnia. These issues began a year ago, starting with him seeing an overturned chair with a cup of water. Six months later, he began to see his late uncle and a group of boys playing around him. Occasionally, he became verbally and physically aggressive. The visual hallucinations and insomnia disturbed the family members and sometimes led to sleep deprivation. The triggers included not getting enough sleep, occurring approximately three times a week. He has no delusions or indications of delirium and has no history of taking medications from other clinics or over-the-counter drugs. His granddaughter did not observe any mood issues, particularly depression.
Regarding his cognition, his granddaughter observed a rapid decline over the past six months (four years after the onset of Parkinson's disease). This decline includes short-term memory loss, characterized by repetitive questioning and forgetting recent events. There were no neurological deficits noted. His mobility has also deteriorated, shifting from independent walking to using a walking frame for assistance in early 2024, and he experienced a total of three falls this year. His basic activities of daily living (ADLs), such as bathing, grooming, and personal hygiene, now require maximum assistance from one person due to bradykinesia and weakness since early 2024. His granddaughter manages his medications. He does not experience urinary incontinence or postural dizziness.
He lives with his 70-year-old wife, son, daughter-in-law (both of whom work as cooks at a kopitiam), and granddaughter.
Upon examination, he has a mask-like facial expression and was not oriented to time, place, or person. His speech was incomprehensible and monotonous. No tremors were observed; however, there was rigidity in both upper limbs, along with bradykinesia. There were no signs of vertical gaze palsy or cerebellar dysfunction.
BP 160/82 mmHg
BP range 150-180/75-82 mmHg
HR 72
UPDRS Part 3- Motor examination during “off “state:
Reflexes over knees and ankles are present and normal, Babinski are down going bilaterally
MMSE 16 (August 2024) > 4 (October 2024)
Investigations:
• HbA1c 5.1
• LDL 1.19
• RPR negative
• Folate 8.9
• Vitamin B-12 286
• FT4 10 pmol/L
• TSH 0.93 mIUL/L
CT brain: Multifocal old infarct with encephalomalacic changes of right parietooccipital region
He was started on Quetiapine 25 mg at night and a Rivastigmine patch 4.6 mg once daily for symptom management. In addition to education provided to his daughter on non-pharmacological strategies for managing his symptoms at home, his medication regimen includes Cardiprin 100 mg once daily, Rosuvastatin 20 mg once daily, Vildagliptin 50 mg twice daily, Perindopril 8 mg once daily, Amlodipine 10 mg once daily, and Madopar 62.5 mg three times a day. Hydrochlorothiazide (HCTZ) and Gliclazide were discontinued during the recent treatment course.
Questions
1. What strategies can be implemented to optimize his vascular risk factors?
2. What might explain his rapid decline in cognitive function, mobility, and basic activities of daily living, leading to total dependence? Would you consider further imaging?
3. What are the potential causes of his hallucinations aside from non-motor complications related to Parkinson's disease?
4. What non-pharmacological interventions can we offer to manage his symptoms?
5. What concerns arise when initiating antipsychotic treatment in patients with Parkinson's disease, and how would your pharmacological approach differ in this case?
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